Your Name: Relationship to Patient: self doctor family/caregiver
Your Email Address:
Your Primary Phone:
Patient's Name:
Patient's Email Address:
Patient's Primary Phone: home phone work phone cell phone pager fax
Patient's Other Phone: home phone work phone cell phone pager fax
Referring Provider:
Insurance: Medicare Medicaid
Other:

Reason for appointment:

-select Priority Level- Normal Urgent, call 330.376.1902 Emergency, call 911

-select How Soon You Prefer- Urgent Within 2 weeks Next month Within 3 months Within a year

My preferred appointment times are:

First Choice:
Day: Mon Tues Wed Thurs Fri
Between: 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM to 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM

Second Choice:
Day: Mon Tues Wed Thurs Fri
Between: 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM to 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM

My preferred location and healthcare provider is:

Akron: -select provider- No preference, please assign Peter Cutri, DO Roswell Dorsett, III, DO DeAnna Frye, PhD Amir C. Mazhari, MD Hugh Miller, MD Lawrence Saltis, MD Laura Samson, PsyD

Belden Village: -select provider- No preference, please assign Frankie Roman, MD

Brunswick: -select provider- No preference, please assign Zachary Lewton, MD

Green (Uniontown): -select provider- No preference, please assign Jose Rafecas, MD Frankie Roman, MD

Hudson: -select provider- No preference, please assign Peter Cutri, DO Laura Samson, PsyD Roger Weiss, DO

Medina: -select provider- No preference, please assign DeAnna Frye, PhD Zachary Lewton, MD Frankie Roman, MD

Ravenna: -select provider- No preference, please assign Roswell Dorsett III, DO DeAnna Frye, PhD Jose Rafecas, MD Roger Weiss, DO

West Akron: -select provider- No preference, please assign Jose Rafecas, MD Frankie Roman, MD Lawrence Saltis, MD

-select Procedure Requested- None or not sure Aquatic therapy BOTOX injection EEG EMG Evoked Potentials Infusion therapy MRI Nerve conduction study Neurodiagnostic Testing Neurology Consultation Neurology Follow Up Neuropsychologic Testing Neurorehabilitation Occupational therapy Physical therapy Sleep consultation Sleep study Speech therapy Other

Comments: